There’s no way around it: when your dog or cat loses a leg, managing pain becomes part of your duty as a pet parent. But the good news is you can do LOTS to help your Tripawd avoid pain. In this episode of Tripawd Talk Radio Dr. Tamara Grubb explains what we can do to keep our three-legged heroes comfortable and mobile for life.
Tripawd Talk Radio Episode #121: All amputee pets will experience some level of pain before, during, and after surgery. But how do you know the best way to control that discomfort? And what pain management treatments are best? Learn how to talk with your vet about proper pain with Dr. Tamara Grubb on this episode of Tripawd Talk Radio.
Tripawd Talk Radio Episode #121: Help Your Tripawd Avoid Pain with Dr. Tamara Grubb
When we learned about Dr. Grubb in a Fear Free Pets pain management webinar, we knew we wanted to have her on Tripawd Talk. And when we found out she was once a Tripawd parent herself, we couldn’t wait to have her as our guest. Her angel dog Lacie is pictured above.
From acute pain and chronic, to NSAIDs and opioids, from acupuncture and rehab, to common pain signals and side effects – we cover it all with Dr. Grubb in this episode! Listen in the player, download it to your phone, watch the video, or read the transcript below.
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Learn more about Dr Grubb’s work in Veterinary Anesthesia, Analgesia and Continuing Education at https://vetaace.com/
Watch Pain Management for Tripawds Interview on YouTube
Guest Bio: If anyone can help your Tripawd avoid pain, it’s Dr. Tamara Grubb, DVM, PhD, DACVAA. She is a Diplomate of the American College of Veterinary Anesthesia & Analgesia with a strong focus in pain management. She owns VET AACE, an anesthesia/analgesia & continuing education consulting practice which serves both small and large animals.
Dr. Grubb is a national/international educator and lecturer, a certified acupuncturist, an Adjunct Professor of Anesthesia & Analgesia and the President of the International Veterinary Academy of Pain Management (IVAPM). In 2022 the World Small Animal Veterinary Association named her Speaker of the Year.
She is co-author of two books, including ‘Veterinary Anesthesia & Pain Management for Nurses & Technicians’. Dr. Grubb’s favorite achievement is winning the Distinguished Teaching Award at two Universities.
Tripawd Talk Radio Transcript:
Pain Management with Dr. Tamara Grubb
TRIPAWDS: [00:00:44] Hello again from Jim and Rene at Tripawds! You are listening to Tripawd Talk Radio episode number 121, and today we’re talking all about pain management for amputee pets.
From acute pain and chronic to NSAIDs and opioids, from acupuncture and rehab to common pain signals and side effects, we cover it all. Doctor Grubb, thank you so much for joining us today.
DR. GRUBB: [00:02:12] Thanks for having me. This is a topic that’s very important to me.
TRIPAWDS: [00:02:17] And to everybody in our community. Hi Doctor Grubb, this is Rene and I am so excited to have you because several months ago I saw you on a fear free webinar and thought, we need to have her on our podcast because you are so good at explaining things in a way that pet parents like us can understand. And today’s topic can get really complicated, and overwhelming, especially when somebody is in the middle of dealing with amputation, recovery or some type of injury with their three legged dog or cat. I know that you’re going to do a great job informing us about this important topic. So thank you so much for being here.
DR. GRUBB: [00:03:02] Thanks for having me. And that’s such a huge compliment because that really is my goal, is for everybody to understand how bad pain is, how to look for pain, and what we should be doing for our pets to control that pain.
How to Recognize Tripawd Pain Signs
TRIPAWDS: [00:03:17] Maybe we can start right there, like prior to surgery, prior to any diagnosis. One thing I have a problem with is how to identify pain. A lot of people don’t know what indicators suggest that their dogs might be in pain.
DR. GRUBB: [00:03:34] Oh, you’re definitely not alone there. There are so many pets in pain that need to come see a veterinarian. But if the pet parent doesn’t recognize pain, then they don’t get in for treatment of pain. And it’s a very common problem.
I totally understand it, because if you’ve never had a pet in pain, you don’t know what to look for, and you think maybe it’s like humans. We talk about our pain, right? If I were in pain right now, I would tell you all about it. And animals don’t do that. And we do it because in our social structure, if I’m telling you about my pain, you might help me. You might send me to a good pain doctor or recommend a person who does acupuncture or something.
But our dogs and cats don’t come from that social world. They come from hiding pain for survival because if they show pain and they look weak, then a predator might eat them. Okay, none of our house pets have predators inside our house, but that’s a very strong evolutionary instinct that’s not going to go away.
We have to look at them and say, “What would pain look like then?”
Because we don’t see pain, we see the impact of pain. What is pain doing to our pet? And that’s manifest primarily in two ways. And one is kind of obvious change in mobility if we’re talking about musculoskeletal pain.
DR. GRUBB: [00:04:57] So a lot of the tripods have that, but it can also look like a change in behavior. And behavior doesn’t just mean I’ve got a really outgoing cat. That’s his behavior. Behavior also encompasses daily habits like grooming and urination defecation.
So if the pet is less interactive, okay, that’s a big behavior change. If it used to be really friendly or maybe it’s starting to hide and it never used to hide, or maybe it’s not grooming as well.
Or maybe the dog’s not asking to go outside to urinate or defecate anymore. Or the cat is urinating outside the litter box and it didn’t used to do that. So when we see behavior changes, we need to think about the problem.
It may not be pain, maybe it’s a disease, maybe it’s because we got a new puppy and the cat doesn’t like it. But that’s still a problem that a veterinarian can help with. How do we integrate the puppy and the cat?
But it’s often pain. And so getting all of us as pet parents to remember that we see the impact of pain is my pet doing something different behaviorally. And that then really should instigate a a visit to the veterinarian. Because again, maybe it’s not pain, but it’s some problem.
And a lot of times it’s pain. So looking for changes in behavior and changes in mobility, that’s what pain looks like.
What about tail wagging? Or eating? How do those behaviors relate to pain signals?
TRIPAWDS: [00:06:27] Oh, I would like to throw this one out there as far as looking for pain. Because what do you think about tail wagging and appetite? A lot of people base their animal’s comfort level on Is their tail wagging? Are they eating? What about those two things in relation to pain and what it looks like?
DR. GRUBB: [00:06:49] You have hit a huge nail on the head. I’m so glad you asked that question. Absolutely. I hear it every day. No, doc, my pet is not in pain because he’s still eating. No, doc, not in pain because his tail is wagging. Exactly. And you know, I hate to say you might be wrong, not you, but the person that says that. But you might be wrong.
You know, tail wagging, it’s just a sign that says, “I’m happy to see you!” And it doesn’t really have anything to do with the physiological physiologic status of that pet at that moment. Right. Just like, “Oh, hey there you are.” Good. So it has no indication of pain or not pain.
And then eating oh my goodness. They eat for survival. Just like they hide pain for survival. So not eating means something. If they stop eating, that means a lot. If they are still eating, that means nothing to do with pain, absolutely nothing.Dr. Grubb
And just think about it. I mean, we’re talking about tripods today, but just think about how bad dental disease can be in some pets. If the pet parent isn’t watching for that, their mouths can be awful, their teeth rotting out. That’s obviously painful. And yet they’re still eating right, and the pain’s right there where they’re eating. So yeah, I’m really glad you asked that.
It’s a big point for everyone, tail wagging. I love it, but it doesn’t mean anything about pain and eating. Again, nothing about pain unless they stop for clarifying.
Pre-Amputation Surgery: How to Help Your Tripawd Avoid Pain
TRIPAWDS: [00:08:19] The big question I have right now in my mind is, Are there things that we can do before amputation surgery to make sure our pets have a comfortable recovery later on? Is there a medication they can be given before surgery? What should we be talking to with our vet about making sure they go through this as comfortably as possible?
DR. GRUBB: [00:09:48] You hit on a bunch of really good things right there. So first of all, the pain management protocol from the vet so that before, during and after is perfect because some most veterinarians don’t do it like this, but there’s still a few probably that give the pain meds before the surgery starts. So maybe an opioid and an anti-inflammatory drug. And then that’s the pain management. And it can’t be that way. This really requires a robust protocol.
So like you said before, during, after. We start that way. Yes that’s awesome. But then during (surgery) we want to do some local blocks and maybe a drip of pain management, an infusion of pain management.
And then after absolutely readdressing pain, stop giving more drugs so that before, during, after is huge. It has to be this robust protocol. And then what if we back it out even a little bit more? So what could we do the week before or the days before, if there’s any underlying pain that we could treat?
Of course, like you said, they’re usually already in pain. So they’re on analgesics. And that’s important to try to control the pain the best that we can. And if it’s not controllable to get that surgery done as soon as we can. We want them on some analgesic drugs before the surgery. And if they’re not in a lot of pain, we could start, you know, a week before even. But we don’t always have that luxury.
Also thinking about their anxiety level. This gets left out a lot and anxiety exacerbates pain. If they are also a very anxious type pet, then we should have them on some anxiolytics ahead of time like Gabapentin, and try to get them kind in a calmer place before the surgery.
What Surgical Drugs and Post-Amputation Pain Control Medications are Best?
TRIPAWDS: [00:11:38] Really interesting because we have noticed a lot more pets getting prescribed Trazodone. Um, generally after surgery, which which we’ll talk about in a bit, but as far as the, analgesics go, what should we be asking for?
DR. GRUBB: [00:11:58] What you should be asking for is what is your comprehensive analgesic protocol? And I’m going to throw the word multimodal out there because it’s sort of my favorite word. And all it means is more than one mode. And like we like we just discussed, we want to start.
We want to have a veterinarian or the veterinary technician maybe talking to us about pain management. It says, what you and I just said, “What do you what this is what we do before, during and after the procedure?”
And these are some of the drugs that we’re going to use, an opioid and an anti-inflammatory, a local anesthetic, maybe ketamine. Right? All of the different drugs that would go into that protocol. We want it to be all encompassing. That’s the biggest descriptor of a balanced, all encompassing, multimodal.
We want to hear that things are being done at different times in the surgery, and that different drugs are being used because they work at different places in that pain pathway or that pain system.Dr. Grubb
We also want to hear from our veterinarian or veterinary technician that plan for recovery. And I don’t mean anesthesia recovery. That’s obvious, but recovery from the surgery. We don’t want to get dumped, right. We we want that continued support. Like what treatments are we going to be using? How can we assess them?
I said treatments on purpose because a lot of times it’s not drugs. It could be an NSAID, plus acupuncture. I’m also a certified in acupuncture, so a big believer in that. And of course there’s laser and physiotherapy. It’s going to have to include a lot. We want that veterinarian to tell us a lot of stuff that they are planning for us or our pet.
What About Pain Control Medications in Different Countries?
TRIPAWDS: [00:13:44] In countries where maybe the pain medications that we receive here in the US and Canada aren’t widely used, what is something that somebody could ask for? I mean, is, is Tramadol completely ineffective? Are there other drugs that people could talk to with their vet about?
DR. GRUBB: [00:14:40] Yeah, absolutely. There are some and I’m going to say it’s kind of disappointing because we don’t have a lot of choices in veterinary medicine, which is no excuse for not trying something. But we don’t have the choices that we would like to have that we need.
The most potent drug classes that should be included in the surgical pain and the surgical protocol for pain are the opioids and the anti-inflammatory drugs and the local anesthetics. Those are huge. You want to hear your veterinarian say that they do local anesthetic blocks.Dr. Grubb
If any of those drugs are missing, and it’s usually opioids because you’re right, not every country has access to opioids. Now, we can’t just say, okay, well, we don’t have opioids. So we’re not going to, we’ll just go without. We need to hear that vet say we are going to to add in some Gabapentin. Not as potent as an opioid, but still we’re trying to to add in other things. We do acupuncture.
A lot of countries where opioids aren’t available, that seems like there might be some more use of physical medicine. And Tramadol. Tramadol is not completely off the table.
Gabapentin is one we know that might help. It’s not that great for the surgical pain itself, but it’s for that ongoing pain that was already there. Because I want to make a quick point if a patient is already in pain. So the reason for the amputation, whatever the painful lesion was, and we cause more pain by doing surgery, those patients have really amplified pain because it’s pain on pain. And so the Gabapentin really is for the pre-existing pain.
DR. GRUBB: [00:16:15] And then again maybe an anxiolytic. There’s a drug called Amantadine, it works in the spinal cord like ketamine does. And I like to use Ketamine drips during the surgery for all of the amputations, anything with pre-existing pain. Not something I would send home obviously, but something in the clinic.
So Amantadine is an option. Tramadol might help some dogs. It’s not as good as we thought it was, as we all know now, but it does work as it’s not a very good opioid in dogs as it is in cats. It’s a very good opioid in cats. But it makes cats very dysphoric. And cats hate the taste. But it does also work as a norepinephrine and serotonin reuptake inhibitor. That is in part of the pain pathway that helps to decrease pain in the spinal cord. It’s called descending inhibition.
As an example, if anybody is familiar with the drug Duloxetine in human medicine, that’s what that drug does. That’s how it works. So Tramadol does have that mechanism of action that can be helpful. That’s another thing to ask for.
Sometimes we’ll put Lidocaine patches at the incision. That’s something that could be explored. And then again asking about where can I go for acupuncture? Where can I go for laser? Where can I go for massage for my pet? So all of those physical modalities too. That was a long story for if we have to replace any of those drugs, if they’re missing, we don’t have a lot of choices.
We have to use more than one choice to replace one of those big, potent drugs, but it can be done.
What’s the Best Way to Choose a Veterinary Clinic for Amputation Surgery?
TRIPAWDS: [00:18:00] We’re seeing pain management concerns in certain clinics where maybe the vets have been practicing a long time or they’re not up to speed on the most recent standards. So what if someone has the liberty of time in selecting a surgeon or a hospital? What type of credentials or accreditation for the clinic should people be looking for, like AVMA or AHHA clinics? What if someone has the time to select a surgeon? What should they be looking for in terms of pain management at that practice?
DR. GRUBB: [00:18:37] Any veterinarian can be really passionate about pain management. So any clinic could be really good. But if we’re looking at ones that might have had more pain training, there’s the Certified Veterinary Pain Practitioner (CVPP) program, through the International Veterinary Academy of Pain Management. So CVPP is a big one.
If that clinic happens to have an anesthesiologist, we are trained in anesthesia and analgesia. Our credentials would be Diplomat D of ACACVAA American College of Veterinary Anesthesia and Analgesia and AAHA clinics, the American Animal Hospital Association. They have pain training in their requirements to be certified as an AAHA clinic.
And you mentioned Fear Free. If people are Fear Free Certified they’re definitely active in pain management. And then you’re right. Another one is ABVP American Board of Veterinary Practitioners. They have pain management training and other specialties too.
Those are probably the most pain focused groups but again, there’s a lot of veterinarians out there that are great at pain management. And you’re right, some that just haven’t upped their knowledge in pain management yet.
How to Talk to Your Vet About their Pet Amputation Surgery Experience
TRIPAWDS: [00:20:03] I know that it can be kind of annoying for somebody like me to say, “Well, I heard on the internet that we should” or “Tripawds said we should ask for this.” What’s a respectable way to talk to your veterinarian about their pain management? I would like to be able to talk to my veterinarian without insulting their knowledge, but yet probing a little bit to make sure that they’re good with pain management.
DR. GRUBB: [00:20:57] Yeah, and I think you should ask that. And honestly, we are taught to be proactive about our own health care, right to ask questions. And so why wouldn’t we ask questions? We’re also taught to do that for family members. Why wouldn’t we do that for the pet? Just asking it as that kind of question and not a “Well, don’t you do this?” or “Well, why don’t you know?” Not a blaming or you know, that’s maybe not the right word, but not antagonistic. Being proactive, we have to ask. And so just saying.
I don’t think a veterinarian or veterinary technician should be offended if you said “I really want to be proactive about my pet’s health care, can you describe your anesthesia and pain management protocol to me?”Dr. Grubb
Doesn’t even have to be the anesthesia. We’re talking about pain, but I couldn’t help that as an anesthetist. Add in all the things we’ve just talked about “I’d like really like to hear what you do before, during and after surgery and then what I can expect to be doing when I return home?”
Just ask it as a question. It’s a valid question to be proactive of. And then, you know, if you didn’t hear quite what you wanted, so pretend you didn’t hear “local anesthetic block.” I think that’s you should say, “Do you do any local anesthetic blocks?”
If they say, because maybe they forgot to tell you, or maybe they just started, and then you could say, “Oh, good, I want that for my pet.”
Your veterinarian wants you to be happy, too.
But if what you hear doesn’t fit what you want for your pet, like, “Wow, I don’t know how to ask any more questions without being antagonistic.” Then, you know, as a veterinarian, I would say we all want you to be happy.
Find the veterinarian that fits you. And again, like you said, if you have the luxury of time, if you don’t, it can be really tough. But find that veterinarian that fits you, that’s that’s passionate about what you’re passionate about. And and pain management is a big part. And, you know, maybe you could ask a few (friends), “A friend of mine’s dog had surgery and this is what happened.”
You’re right. It’s with any profession, as soon as you say “I read it on the internet.” Okay, so, Doctor, Google’s license is better than mine?” You know, it’s just a tough way to, to start out. But there is a place for it though, because again, the veterinarian should be wanting you to be the advocate for your pet.
You know, at some point, as you’re listening, saying, “I really tried to look things up so I would have some knowledge about what you’re explaining to me.” So like you’re deferring, right? Like, “I know you’re the vets, but I tried to understand it and I found some sites that said X was good,” you know, whatever. There’s definitely a way to introduce it, um, without being, uh, challenging. Right.
After Amputation: How Do We Help Our Tripawd Avoid Pain During Recovery?
TRIPAWDS: [00:23:58] Let’s say we found the vet who we feel good about. We, you know, their their pain management seems like it’s up to speed. And and it’s somebody we want to work with. How do we know that our pet is comfortable once they’re back in our hands? What is the best way to gauge their comfort level?
Because in our experience with our community and our own pets, it’s it’s been like when they’re on drugs, pain, drugs, you don’t know if they have too much or too little and they can be really zonked out. And maybe that’s a good thing, or maybe that’s a bad thing. It’s very hard for us to tell.
DR. GRUBB: [00:24:43] Right, right. And what we want to see returning fairly quickly are those normal behaviors. So your dog coming back and wanting to sit with you on the couch, or your cat playing with a little ball, they just spit at first, right. Just like, ‘oh there’s my ball , bat bat oop, that’s enough, I’m not quite ready.”
But starting to see that return of the pet, the normal behavior and the you’re right that immediate those first couple of days they may be seeming a little too sedate. And part of that, if anybody that’s been through surgery knows it’s just exhausting. So you’re tired afterwards and you don’t bounce back right away.
They may seem a little sedate or quiet, but you’re right, if that continues, then maybe one of the drugs needs to be decreased because we don’t want them to stay sedate because then they’re not eating normally. They’re not keeping themselves hydrated. We need them to go through all those normal functions of life.Dr. Grubb
And pain is such an individual response that there’s some trial and error in using these drugs in each patient, and then the response to the drugs is individual. So that’s adding the trial and error. But I would say we just kind of normal tiredness, maybe taking more naps those first couple of days after surgery is normal.
But between naps you want an awake and alert pet. You want them to be interactive with them the way they were before. So that’s what you want to see is kind of that slow return to the normal behavior.
And if they’re not returning within a couple of days when you’re not seeing progress, definitely need a recheck. Because either you’re right, the pain meds aren’t right, or maybe an infection is setting in or something different is going on, but something that would would prompt a veterinary visit so that slow return.
I really recommend using quality of life scales that first week or so. Like we’re just talking about post surgery now. But then as they recover from that starting quality of life scale so that you can see how they’re doing long term.
How Do We Customize Pain Control for Our Tripawd?
TRIPAWDS: [00:26:58] Can you explain, like how often pet medications should be adjusted? And should we allow time to evaluate whether that adjustment took place? Gow do we ride this pain management roller coaster with our dogs and cats?
DR. GRUBB: [00:27:54] Yeah, you’re right, there can definitely be too much adjustment and yeah, I see a lot of that too. Or people that just stop giving the drugs, they don’t think they’re working and then just are. We see it all the time when a pet parent will bring a bottle of the drugs back in time to remove the stitches and plunk it down on the counter and go, ‘Here, I’m going to return these. My pet didn’t need them.” Uh! Right. Yes, they did. So really, really pushing that.
Have to stay the course again. This pet has had ongoing pain already and now has more pain on top of it. So we have to stay on top of that pain. And if they’re like we said, if they’re a little bit groggy those first couple of days, as long as they’re eating a little bit, drinking okay. But then we want that to be dissipating by day 3 or 4.
Drugs take time to to make a change. And in this group of drugs that we’re talking about for recovery, the anti-inflammatory drugs are the ones we really need to have the pet taking. We need to control that inflammation and their once a day pretty easy to do. Leave them on unless there’s a side effect. Don’t take them off of those unless again something bad is happening.Dr. Grubb
The other drugs like adding in the Gabapentin or the Amantadine, they’re not as powerful. So they’re we call them adjunctive drugs. They’re helping the NSAID and they’re slower to take effect. So just have to leave them on. Unless you overdose the pet with Gabapentin. And it was so sedated it couldn’t get out of bed, leave it alone.
DR. GRUBB: [00:29:31] If it even if it’s just mildly sedate, because you guys have probably seen this with your experience, if they very often develop a tolerance to that sedation with Gabapentin. So if you leave it on for several days, then you know, like by day 4 or 5, the Gabapentin is helping and they’re no longer sedate.
Unless there is something major as a side effect, leave the treatment on, leave it going. And also again, include things like acupuncture that has a longer duration effect and that helps decrease that roller coaster a little bit.
Relying on some of the physical modalities and not just the drugs can also help smooth out that recovery. And unfortunately it’s just a tough time. We have to again stay the course, write it out.
You’re going to get better. But they just had surgery pain on top of chronic pain. And so it’s going to be tough for a little bit.
And you know it’s it’s not unheard of. I have done it myself to if we’re really fighting the roller coaster to re-hospitalize the patient and do a drip of the pain drugs, to really try to break that pain cycle and that that may be an option with, with veterinarian. ‘I just need to hospitalize your dog or cat for a day or two, and we need to get this under control because we can’t do drips at home.’ Doing them in the clinic is really the option.
DR. GRUBB: [00:31:05] That might happen. Another thing is another question that you might ask a veterinarian that would help in this scenario is one thing that that is very exciting that we see in human medicine. And now starting in veterinary veterinary medicine is longer duration drugs that are traditionally used for acute pain.
I was I keep talking about the local blocks. You think I you must think I invented them, or I get a royalty on local blocks, but they’re definitely helpful for amputation pain. And now there is a local anesthetic block that lasts 72 hours. And so that’s really going to cover a lot of that first pain.
You might ask the veterinarian if they use that drug. And in cats there’s an opioid buprenorphine that lasts for four days. We can put it on in the hospital and it’s already in the cat. So ask the veterinarians, if they use some of those longer lasting drugs. Can is also helpful because it does decrease the pain in this this rocky part that we’re talking about.
The more robust we are with our pain control when we do the surgery and then even before the surgery, then the more controllable the pain is probably going to be.
I can’t say 100% because it’s an individual sensation. But yeah, getting your community to just going to have to ride this out a little bit. But conferring with your vet and asking, is there something more we could do even if it’s in the hospital, maybe a question in some of these patients it’s very valid.
TRIPAWDS: [00:32:39] That’s something that we have seen work in some really tough pain management cases. We have seen some members animals go back in and have a drip to break that cycle. I’m thinking of a bulldog who had some horrific pain, and he was readmitted back to University of Pennsylvania’s vet school. And they fixed it. They got it under control. And that dog went on to have a really good quality of life.
When Does the Amputation Recovery Rollercoaster end?
TRIPAWDS: In your experience, what is the general time frame that we can expect this kind of roller coaster to slow down and just get life back to normal again? Does it depend on the age, breed, species?
DR. GRUBB: [00:34:28] Well, great question. And you know, you have seen so much of it. You probably have a better idea just from your experience how long it should take. And, you know, I can see when they when the pet goes home and the, the those, the drugs that were used for surgery, they’re going to still even though the drugs are gone, the pain itself because of where the, the drugs working in that pain pathway or pain system, it’s suppressed a little bit. And then they’re, you know, they’re feeling pretty good.
And then all of a sudden those wear off and probably some of them might have been a little too active. Then all of a sudden too, they get these new sources of pain. I guess we all know that that their weight has been equally distributed on four limbs, or it may be not all distributed, because, again, there were some pain and the reason the limb was amputated, but they still had some balance to their body.
Put yourself in your pet’s paws
And now they have three legs and now they’re twisted, right? Their whole thorax and abdomen and hips are a little bit talk and they’re trying to rebalance. And that’s hard so they’re trying to figure this out. As this is all happening. Okay twist yourself right now you two. And what do you feel? You feel some muscle stretching that that normally aren’t. And now try to walk!
You feel some muscles needing to be used that weren’t used as much. And they develop these a lot of secondary secondary sources of pain right at about that week just from the change in balance.
That’s why I love, again acupuncture and massage because we start to palpate those those pets. We often feel trigger points. Right. Those horribly knotted muscles that are so painful because they’re having to move and to stand in this whole different way and their muscles are reacting to that.
That’s what we usually think we’re seeing at about that week, is this new source of pain. And the reason I’m saying that I see it often enough, and sometimes those pets come back in with a comment from the pet parent saying, “Maybe we should just euthanize doc because he’s worse.” And I go, “Wait a minute. I mean, that’s always an option. That is ultimate pain relief, but let’s touch your dog. Let’s see what’s going on here. Oh, see how he jumped when I palpated that muscle.”
So between the drugs wearing off and new sources of pain kicking in I think you’re right. Like 5 to 7 days or so. And that’s why starting the rehab, the acupuncture, the massage, the leash walks, the whatever physical components you’re going to do. That’s why it really needs to start as soon as possible.
Acute Pain versus Chronic Pain
TRIPAWDS: [00:37:06] Could you explain quickly the difference between acute and chronic pain for our listeners?
DR. GRUBB: [00:37:29] Absolutely. So acute pain is pain right now, your surgical pain, you wake up from surgery and you are in acute pain. Chronic pain of course is that ongoing cancer pain arthritis pain. And I’m glad you asked because they’re actually quite different.
The acute pain from surgery is mostly pain from inflammation. So the anti-inflammatory drugs will help a lot.
Chronic pain is it’s it’s called chronic, you know, lasts a long time. Life probably for most of our pets or patients. Right. But long duration usually for life for most of these diseases. That pain is not just acute pain of inflammation that lasts a really long time. Inflammation is a part of it. But what has made it chronic is some kind of change in that pain system, that pain pathway, something in the spinal cord, a new receptor opening or irritation of a nerve. There’s some other cause. It’s not just the inflammation.
Chronic pain is actually what we call pathologic pain. Acute pain is physiologic.
It’s normal. We need that. It’s survival right. That if something is acutely painful you move away from it. Right. You survive chronic pain because it comes from other sources. As we just said, it’s not all inflammation. It really isn’t protective.
Treating Long Term Tripawd Pain
Phantom limb pain is a phrase that we use a lot with the amputees. Right. And pain from a leg that’s not even there anymore. That’s obviously not physiologic. That’s not normal. That’s not protective. So chronic pain is also called maladaptive. It’s not a normal adaptation of the pain pathway.
We’re dealing with something that’s very very complex. Whereas surgical pain yeah it can be awful. But it’s a little more straightforward and easier to control. And now like I said in these patients we’ve got the acute the surgical inflammatory pain cut nerves on top of the chronic. What’s going on in that spinal cord? What’s going on iin the peripheral nerves? It’s very complicated for those patients, so again explains the roller coaster.
TRIPAWDS: [00:39:38] I would love to get your thoughts about any potential long term issues that may happen from leaving an animal on pain control medications. A lot of people wonder, do they get withdrawals if we take them away? I mean, what are your thoughts on that?
You know, the side effects of pain meds are a lot less frequent than the side effects of pain.Dr. Grubb
DR. GRUBB: [00:41:43] I’m going to explain. I’ll say I just shot for dramatic pause there. But pain is causing side effects and pain is a disease. Chronic pain is a disease. We treat the pain right. We can’t always cure whatever caused it. We don’t always know. Like I said, it might be a change in the spinal, or whatever. Pain is a disease. Let’s treat the pain.
We wouldn’t leave another disease untreated, especially if it impacted quality of life the way that pain does. But it is true. We want to use the safest medications that we can. And that’s why for some of the medications, like the anti-inflammatory drugs, we as a veterinarian might ask you to come back in more often for blood work than you used to. To come in just so we can be sure that the drug is still safe for your pet and that it’s still working. There’s a big fear with NSAIDs, leaving them on for life. And I hear it a lot. Just like you guys hear it in your community.
DR. GRUBB: [00:42:45] Or the other one I hear a lot is “I don’t want to start him on drugs now. He’s so young.” We’re not treating age, we’re treating pain. So let’s do we start when pain starts. But like the anti-inflammatory drugs, if they are going to cause a side effect, it usually happens in the first two weeks.
There’s no evidence that the longer they’re on it, the more likely they are to have a side effect. It’s they either have a side effect to the drug or they don’t.
Okay, it’s not that black and white, but there’s not that many shades of gray. So leaving them on for life if they need it, no problem. As long as yes, we’re checking. And then if that one is causing a side effect, okay, we go on to the next treatment.
As you guys know, you’ve been through it enough. Sometimes it’s a little bit of trial and error to find the one that works and is safe in that pet. But I’m really more worried about what pain is doing to that pet than what the drugs are doing to that pet. With reason, of course, again, with medical checkups.
Pain Signs versus Medication Side-Effects: How to Know the Difference
TRIPAWDS: [00:43:47] Do you have any tips for someone to identify what may be a side effect, or it might be a pain signal, so they can determine whether or not it is the medication? Or is that just totally dependent on the prescriptions going on?
DR. GRUBB: [00:44:21] Yeah, some of all of that definitely depends a bit on the prescriptions, especially if it’s a drug like Gabapentin that can cause some sedation. Right? We know that we might see behavior change. We might see sedation. But a drug like an NSAID where the side effect, the most common side effect is GI upset. So vomiting okay I gave an NSAID, they vomited. I can say that’s probably the drug. But then just again with the signs of pain, we’re still looking for those changes in behavior.
Again with a sedating drug that can be harder. But with NSAIDs the appropriate dose of Gabapentin with not with physical medicine, any change in behavior could be pain. And I don’t know if I’m quite answering your question, but clarify for me if I’m not.
TRIPAWDS: [00:45:09] Like you said, pain is a disease. And for Tripawds, unfortunately, they tend to be more at risk of ongoing chronic pain than a four legged dog would. And that’s just something to be really mindful of as we go through life together. Even a dog who doesn’t have cancer can be subject to all of these side effects of this disease called pain.
Doctor Grubb, we are just thrilled to have you here with all of this wonderful information. This is going to be so helpful for people. We’re running out of time. We we’re going to go over a whole lot of other stuff. Is there anything you’d like to add for our for our community?
Always Consider Your Pet’s Quality of Life
DR. GRUBB: [00:46:50] I just want to reiterate, I know I’ve said it a couple times, but just reiterate with the Tripawd. And again, I’ve been through it through it with you too.
Assess your pet’s quality of life, not just the Tripawds, any pet. It can be something just as simple as saying, “Is today a smiley face day? A frowny face day? Or a straight smile face? Right? Like I don’t know what to call that one. In the middle, there’s a smile or frown, and in the middle it’s just flat lips.
TRIPAWDS: [00:47:25] Neutral.
DR. GRUBB: [00:47:26] Neutral. Thank you. Because you know your pet and you can tell. And there’s also something to add called the client specific outcome measurement, a CSOM. It’s something we use even in research where I say to you, ‘What does your dog do that would tell you he’s not in pain or he’s having a good day?” And maybe you’d say, “Well, he’d go get his ball, even if it’s just once.” Right? Okay. He’ll have the ball because each pet is different.
What is it in their life that they do that makes you feel like they’re they’re not in pain? They’re having a good day, then put it on your calendar. As they progress they’re getting better and getting worse because that’s how life is. I start doing it every day in those pets and on my calendar. As long as there is mostly smiley face days, then great. We keep going. If we start seeing a lot of neutral faces, um, start thinking about maybe their pain is too much for them and it’s about them. It’s not about us.
We have to say goodbye sometime. It’s about not letting them be in pain. And then if we start getting in frowny faces, that’s when I usually I ask the question, “Who are we doing this for? We’ve tried everything we can to get them out of pain. And now is this for the pet or for us?”
Because we have the blessing to relieve their pain. And that’s to me, what every pet deserves. In the end, when we’ve done it, when we we are out of options. Not right now. We’re still in our early stages in this conversation, but if we’re out of option, it really it’s about the pet always.
TRIPAWDS: [00:49:02] It sounds like it’s important to stick to that schedule, follow your best recommendations, and possibly keep a journal to identify the pain management on a day to day to day basis.
That’s why we encourage people to start their Tripawds blogs, to share their story and also document their own progress. We’re definitely going to recommend that as well as provide links to all of these things that you mentioned. And again, can’t thank you enough for your time.
DR. GRUBB: [00:49:26] Thanks back for having me. I really do obviously like to talk about pain management, and I do love those Tripawds.
Tripawds Pain Management Resources
Is My Tripawd in Pain?
Tripawds Pain Management Articles & Vet Interviews
Lap of Love Quality of Life Quiz:
Pain Free Cats:
Example of a CSOM Scale for Dogs:
Example of a CSOM Scale for Cats:
Download the BEAP Pain Signs Chart for Dogs:
Download the Guide to Acute Pain Guide for Cats:
International Veterinary Academy of Pain Management